Millfield English Language Holiday Courses
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1 Form 1 Enrolment Details and Afternoon Options Millfield English Language Holiday Courses Easter 2015 Application Form years For an instant response you can complete the application form online at: Please begin the application process by completing the Student Name, and indicating the required length of stay - one or two weeks. Student Name Please tick P to indicate the required length of stay 1 WEEK Sunday 29 March - Sunday 5 April 1 WEEK Sunday 5 April - Sunday 12 April 2 WEEKS Sunday 29 March - Sunday 12 April Afternoon Options Please choose just one course per week. Please tick P the following boxes. Please note that students may combine courses, e.g. 1 week Preparation for UK Schools and 1 week Sports & Recreation. EASTER 2015 WEEK 1 Sunday 29 March - Sunday 5 April WEEK 2 Sunday 5 April - Sunday 12 April Preparation for UK Schools Must have intermediate English. o o Sports & Recreation Choice of many different sports & activities. o o To help with the quick processing of your application and to guarantee a place, please make sure that all forms have been completed and returned to the course administrators as soon as possible. Please submit this application by one of the following methods: by to mahc@millfieldenterprises.com, by fax to +44 (0) or by post to the address below. If you require assistance in completing these forms please contact the course administrators on the telephone numbers below. Millfield English Language Holiday Courses Millfield Enterprises, Street, Somerset, BA16 0YD, United Kingdom T +44 (0) /458/319/326 F +44 (0) E mahc@millfieldenterprises.com
2 Form 2 Student Information Please complete this form in block capitals (e.g. PETER SMITH). Please print clearly in black ink. If you will be applying for a Visa to travel to the UK please list the student s passport details below which we will list on the student s confirmation letter. Please also attach a copy of the passport to this application form. For Visa information please visit: Passport Number of Issue Place of Issue Expiry Student Details Family Name Nationality First Name(s) Country of Birth Gender (please tick P ) Male Female Day Month Year of Birth Agent Stamp If the student would prefer to share a room with a friend, please state their name below: We will do our best to meet any requirements, however, please note that rooms are subject to suitability and availability. Language Information First Language (mother tongue) Level of English (please tick P one only) Beginner Elementary Intermediate Advanced T-Shirt Size All students will receive a free T-shirt, please tick P to indicate size Small Medium Large Parent/Guardian Details Title (Mr/Mrs/Ms/other) Family Name First Name(s) Tel (home) Address Country Tel (mobile) Postcode Fax General Information Has the student attended a Millfield English Language Holiday Course previously? How did you hear about Millfield? Friend Brochure Internet Agent Other (please state)
3 Form 3 Student Medical Information Office use only Input date & initials Family Name First Name(s) Please tick P Day Month Year Male Female of Birth Age Nationality A Nurse or an agreed member of staff is on duty throughout the course to treat your child and administer the following over-the-counter medicines: Paracetamol tablets or sugar-free suspension, throat lozenges, anti-histamine and travel sickness tablets. Please tick P if you are NOT happy for this treatment to be given and explain your reason Please note that all medication brought on campus must be given to the Residential Co-ordinators upon arrival. For reasons of safety, there are strict regulations for the management of medicines. We are only able to accept responsibility for drugs licensed in the UK. Please do not send medicines with your child unless prescribed by a Doctor together with an English translation. Has your child suffered in the past from any major illness or injury? If yes, please give details (please tick P ) Does your child suffer from any current medical issues of which we should be aware? If yes, please give details Is your child currently taking any long-term or repeated medication? If yes, please state the name, dosage and time for the medication to be administered. Does your child have any significant allergies or special dietary requirements? If yes, please give details Parent/Guardian with parental authority. Please sign to confirm the information on this form is correct. Signature Print Name Please provide us with two emergency contact names and numbers where we can reach you, or a suitable alternative, for contact at any time of the day or night. Emergency Contact (name) Relationship (e.g. parent/guardian) Phone Number (with country/area codes) Emergency Treatment In the event of an emergency, staff will make every reasonable effort to contact a parent or legal guardian before permitting treatment to proceed as advised by the medical authorities present. Please inform us immediately if any of this information changes. This information will be accessed and used by staff who are responsible for looking after the welfare of your child.
4 Form 4 Student Travel Details Please tell us your travel plans before 2 March 2015 even if you are not using the Millfield airport transfer service Student Details Student Name Office use only Input date & initials Age (at time of travel) Parent/Guardian/Agent travel contact name: Please make sure you are contactable 24/48 hours prior to departure in case we need to reconfirm the travel plans. Contact mobile/telephone: Day Method of Travel (please tick P one option only) Do you require a standard airport transfer? Do you require a private taxi? Do you wish to make your own arrangements? Please complete section 1 Evening Please contact Tony Dubens directly to arrange times and costs then complete section 2 E tonydubens@gmail.com T +44 (0) W Please complete section 2 Section 1 (for students requiring standard airport transfers) Airport Arrival Please tick Sunday 29 March Section 2 (for students arranging a taxi or making their own arrangements) Arrival at Millfield Arrival time Name of accompanying adult P to indicate on which date you will require an arrival transfer: Sunday 5 April Unaccompanied Minor Please tick P if the student will be travelling as an unaccompanied minor (this must be arranged with the airline directly) Travelling from Airport Please tick P to indicate which airport you will be arriving at: Bristol Heathrow Gatwick Terminal no. Flight no. Flight arrival time Airport Departure Please tick Sunday 5 April P to indicate on which date you will require a departure transfer: Sunday 12 April Unaccompanied Minor Please tick P if the student will be travelling as an unaccompanied minor (this must be arranged with the airline directly) Travelling to Airport Please tick P to indicate which airport you will be departing from: Bristol Heathrow Gatwick Terminal no. Flight no. Flight departure time You can contact Mark Greenow with any urgent questions or travel enquiries on the day: markg@millfieldenterprises.com or Telephone +44 (0) All students will be met by a Millfield representative who will be wearing a red Millfield T-shirt and carrying a Millfield sign All students must report and introduce themselves to our representatives as soon as they land/arrive All student must go to the Information Desk in the airport if they cannot find our representatives, or phone Mark Greenow on the details above Some airlines will request details of the name and address of an individual responsible for meeting the students, please give the following information: Mark Greenow, Millfield Enterprises, Street, Somerset, BA16 0YD, United Kingdom or telephone +44 (0) As flights land at different times, some students will inevitably have to wait with our staff for other students to arrive, please be prepared for this, but remember - we want to get all students to Millfield as quickly as possible Departure from Millfield Departure time Name of accompanying adult Please inform us immediately if any of this information changes. Please submit this form to the course administrators by one of the following methods: by to mahc@millfieldenterprises.com, by fax to +44 (0) or by post to Millfield Enterprises, Street, Somerset, BA16 0YD, United Kingdom.
5 Form 5 Course Fees Length of Stay Please tick to indicate the student s choice of week blocks. As a special promotion for Easter 2015, if you book a two week course, you are eligible for a 50% discount on the second week s course fees. This discount has already been allocated to the cost given below. Please note that the discount applies to course fees only and does not apply to airport transfers. Please tick P to indicate the student s choice of week blocks. 1 week weeks 1710 Full fees will be retained if students cancel on or after 2 March Standard Airport Transfers If the student will require a standard airport transfer please tick P which airport. The transfer prices are for return journeys (arrival and departure travel) on the arranged Sundays only. Halve the cost if only one way is required. Students arriving at Gatwick will be collected for onward travel via Heathrow. Bristol (1 hr) 110 Heathrow (2½ hrs) 205 Gatwick (3½ hrs) 250 Total Course Fees Please calculate the total amount due by writing the figures in the applicable boxes. Confirmation documents can be sent by DHL (international courier) at a cost of 60 Course Fees + Airport Transfers + DHL = TOTAL Please note: a 10 administration fee will be charged for each course change per student, once the application has been processed. I have read, clearly understood and accept the Terms & Conditions Signature of Parent or Guardian Payment This section must be completed. Please tick P whether you will be paying the 300 deposit or full course fees at this stage. Please note, for those paying 300 deposit, the remaining balance will be due by 2 March I am paying the deposit of 300 I am paying the full course fees of (please state the amount you are paying) Please note that any booking made on or after 2 March 2015 must be accompanied by full payment. Please tick P to indicate your chosen method of payment Sterling Cheque (Payable to Millfield ) Credit/Debit Card (Complete Section 1) Bank Transfer (Complete Section 2) Section 1 Mastercard/Visa/Amex/Maestro Card. Card Expiry Valid From Issue. Security Code Cardholder Name (please print) Cardholder Signature If you have paid the deposit only, and are paying by credit/debit card, the full balance will automatically be deducted on or just after 2 March Alternatively, please ensure that Millfield receives the balance by this date. In line with current legislation, all card details will be destroyed once all balances have been paid in full. Section 2 To make payment by Bank Transfer please use these details: IBAN (International Bank Account Identifier) GB21 LOYD BIC (Bank Identifier Code) LOYDGB21241 SWIFT Code LOYD GB2L Address: Lloyds TSB Bank, 64 High Street, Street, Somerset, BA16 0ED Account : Sort Code: Account: Millfield I understand that I will be responsible for any charges incurred when payment is made by Bank Transfer (please tick ). Please complete and /fax to us with a copy of your Bank Transfer. P
6 Millfield English Language Holiday Courses Millfield Enterprises Street Somerset BA16 0YD, UK T +44 (0) /458/319/326 F +44 (0) E mahc@millfieldenterprises.com W
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